{{ header }} 
{% include 'fastor/template/new_elements/wrapper_top.twig' %}

<p>{{ text_description }}</p>
<form action="{{ action }}" method="post" enctype="multipart/form-data" class="form-horizontal">
  <fieldset>
    <legend>{{ text_order }}</legend>
    <div class="form-group required">
      <label class="col-sm-2 control-label" for="input-firstname">{{ entry_firstname }}</label>
      <div class="col-sm-10">
        <input type="text" name="firstname" value="{{ firstname }}" placeholder="{{ entry_firstname }}" id="input-firstname" class="form-control" />
        {% if error_firstname %}
        <div class="text-danger">{{ error_firstname }}</div>
        {% endif %} </div>
    </div>
    <div class="form-group required">
      <label class="col-sm-2 control-label" for="input-lastname">{{ entry_lastname }}</label>
      <div class="col-sm-10">
        <input type="text" name="lastname" value="{{ lastname }}" placeholder="{{ entry_lastname }}" id="input-lastname" class="form-control" />
        {% if error_lastname %}
        <div class="text-danger">{{ error_lastname }}</div>
        {% endif %} </div>
    </div>
    <div class="form-group required">
      <label class="col-sm-2 control-label" for="input-email">{{ entry_email }}</label>
      <div class="col-sm-10">
        <input type="text" name="email" value="{{ email }}" placeholder="{{ entry_email }}" id="input-email" class="form-control" />
        {% if error_email %}
        <div class="text-danger">{{ error_email }}</div>
        {% endif %} </div>
    </div>
    <div class="form-group required">
      <label class="col-sm-2 control-label" for="input-telephone">{{ entry_telephone }}</label>
      <div class="col-sm-10">
        <input type="text" name="telephone" value="{{ telephone }}" placeholder="{{ entry_telephone }}" id="input-telephone" class="form-control" />
        {% if error_telephone %}
        <div class="text-danger">{{ error_telephone }}</div>
        {% endif %} </div>
    </div>
    <div class="form-group required">
      <label class="col-sm-2 control-label" for="input-order-id">{{ entry_order_id }}</label>
      <div class="col-sm-10">
        <input type="text" name="order_id" value="{{ order_id }}" placeholder="{{ entry_order_id }}" id="input-order-id" class="form-control" />
        {% if error_order_id %}
        <div class="text-danger">{{ error_order_id }}</div>
        {% endif %} </div>
    </div>
    <div class="form-group">
      <label class="col-sm-2 control-label" for="input-date-ordered">{{ entry_date_ordered }}</label>
      <div class="col-sm-3">
        <div class="input-group date">
          <input type="text" name="date_ordered" value="{{ date_ordered }}" placeholder="{{ entry_date_ordered }}" data-date-format="YYYY-MM-DD" id="input-date-ordered" class="form-control" />
          <span class="input-group-btn">
          <button type="button" class="btn btn-default"><i class="fa fa-calendar"></i></button>
          </span></div>
      </div>
    </div>
  </fieldset>
  <fieldset>
    <legend>{{ text_product }}</legend>
    <div class="form-group required">
      <label class="col-sm-2 control-label" for="input-product">{{ entry_product }}</label>
      <div class="col-sm-10">
        <input type="text" name="product" value="{{ product }}" placeholder="{{ entry_product }}" id="input-product" class="form-control" />
        {% if error_product %}
        <div class="text-danger">{{ error_product }}</div>
        {% endif %} </div>
    </div>
    <div class="form-group required">
      <label class="col-sm-2 control-label" for="input-model">{{ entry_model }}</label>
      <div class="col-sm-10">
        <input type="text" name="model" value="{{ model }}" placeholder="{{ entry_model }}" id="input-model" class="form-control" />
        {% if error_model %}
        <div class="text-danger">{{ error_model }}</div>
        {% endif %} </div>
    </div>
    <div class="form-group">
      <label class="col-sm-2 control-label" for="input-quantity">{{ entry_quantity }}</label>
      <div class="col-sm-10">
        <input type="text" name="quantity" value="{{ quantity }}" placeholder="{{ entry_quantity }}" id="input-quantity" class="form-control" />
      </div>
    </div>
    <div class="form-group required">
      <label class="col-sm-2 control-label">{{ entry_reason }}</label>
      <div class="col-sm-10"> {% for return_reason in return_reasons %}
        {% if return_reason.return_reason_id == return_reason_id %}
        <div class="radio">
          <label>
            <input type="radio" name="return_reason_id" value="{{ return_reason.return_reason_id }}" checked="checked" />
            {{ return_reason.name }}</label>
        </div>
        {% else %}
        <div class="radio">
          <label>
            <input type="radio" name="return_reason_id" value="{{ return_reason.return_reason_id }}" />
            {{ return_reason.name }}</label>
        </div>
        {% endif %}
        {% endfor %}
        {% if error_reason %}
        <div class="text-danger">{{ error_reason }}</div>
        {% endif %} </div>
    </div>
    <div class="form-group required">
      <label class="col-sm-2 control-label">{{ entry_opened }}</label>
      <div class="col-sm-10">
        <label class="radio-inline"> {% if opened %}
          <input type="radio" name="opened" value="1" checked="checked" />
          {% else %}
          <input type="radio" name="opened" value="1" />
          {% endif %}
          {{ text_yes }}</label>
        <label class="radio-inline"> {% if not opened %}
          <input type="radio" name="opened" value="0" checked="checked" />
          {% else %}
          <input type="radio" name="opened" value="0" />
          {% endif %}
          {{ text_no }}</label>
      </div>
    </div>
    <div class="form-group">
      <label class="col-sm-2 control-label" for="input-comment">{{ entry_fault_detail }}</label>
      <div class="col-sm-10">
        <textarea name="comment" rows="10" placeholder="{{ entry_fault_detail }}" id="input-comment" class="form-control">{{ comment }}</textarea>
      </div>
    </div>
    {{ captcha }}
  </fieldset>
  {% if text_agree %}
  <div class="buttons clearfix">
    <div class="pull-left"><a href="{{ back }}" class="btn btn-danger">{{ button_back }}</a></div>
    <div class="pull-right">{{ text_agree }}
      {% if agree %}
      <input type="checkbox" name="agree" value="1" checked="checked" />
      {% else %}
      <input type="checkbox" name="agree" value="1" />
      {% endif %}
      <input type="submit" value="{{ button_submit }}" class="btn btn-primary" />
    </div>
  </div>
  {% else %}
  <div class="buttons clearfix">
    <div class="pull-left"><a href="{{ back }}" class="btn btn-default">{{ button_back }}</a></div>
    <div class="pull-right">
      <input type="submit" value="{{ button_submit }}" class="btn btn-primary" />
    </div>
  </div>
  {% endif %}
</form>

<script type="text/javascript"><!--
$('.date').datetimepicker({
  language: '{{ datepicker }}',
  pickTime: false
});
//--></script> 

{% include 'fastor/template/new_elements/wrapper_bottom.twig' %}
{{ footer }}